L10: Abdominal Exam Flashcards
Abdominal Landmarks
What are the abdominal quadrants?
What are the abdominal sections?
- Quadrants
- Right Upper Quadrant (RUQ)
- Left Upper Quadrant (LUQ)
- Right Lower Quadrant (RLQ)
- Left Lower Quadrant (LLQ)
- Sections
- Epigastric
- Umbilica
- Hypograstric or Suprapubic
Abdominal Quadrants
What sequence do you perform the following elements in?
Auscultation, Inspection, Palpation, Percussion
- Inspection
- Auscultation
- Percussion
- Palpation
Abdominal Exam: Inspection
What are you inspecting for?
- General appearance of the patient
- Contour/Shape/Symmetry
- Distention
- Hernias/Bulges/Masses
- Peristalsis/Pulsations
- Skin markings
Inspection: Contour/Shape
Define:
Flat
Rounded
Scaphoid
Protuberant
Protuberant Abdomens
What can cause protruberant abdomens?
Umbilical Hernia
What is it?
Herniation of abdominal contents through a defective umbilical ring
Incisional Hernia
What is it?
Herniation of abdominal contents through a previous incision site
Diastasis Recti
What is it?
How to test/observe?
Benign, separation of the rectus abdominis muscles
Abdominal contents form midline ridge
Obvious with flexion of neck “lift your head up”
Ventral Wall Hernias
When to check for ventral wall hernias?
Technique?
- If you suspect but do not see an umbilical or incisional hernia
-
Techniques:
- Ask patient to raise head and shoulders off the table
- Ask patient to raise both legs off the table
- Ask patient to perform Valsalva maneuver
- Bulge of hernia will usually appear with this action
Peristalsis & Pulsations
What are they?
Indication if observed?
- Peristalsis (visible waves of movement seen beneath the skin)
- Can be seen in very thin people
- Increased peristaltic waves of intestinal obstruction
- Pulsations
- Normal aortic pulsation is frequently visible in epigastrium
- Look for increased pulsation of abdominal aortic aneurysm
Skin Markings: Ecchymosis
What is it?
Ecchymosis: a discoloration of the skin resulting from bleeding underneath, typically caused by bruising
Can be seen in intraperitoneal or retroperitoneal hemorrhage
Skin Markings: Striae
Pink-purple striae of Cushings
Skin Markings: Dilated Veins
- Abdominal wall veins normally scarcely visible
- Prominent veins most commonly suggest portal hypertension from cirrhosis
- Portal hypertension promotes collateral venous circulation radiating from the umbilicus to the abdominal wall (Caput medusa)
Auscultation
Purpose of auscultation
Why is auscultation performed second?
-
Purpose:
- Assess bowel sounds noting frequency and character
- Assess for bruits (atherosclerotic disease)
-
*Second phase of abdominal exam
- Done before percussion or palpation to evaluate the activity of the intestines before altering bowel sounds with abdominal wall pressure
Bowel Sounds
- Where do you auscultate for bowel sound?
- What is the frequency of bowel sounds?
- Character of bowel sounds:
- What is normal?
- What is abnormal?
- Generally completed in all four quadrants
- Frequency: 5-34 per minute
- Character:
- Active/Normal
- Clicks and gurgles
- Prolonged gurgles of hyperperistalsis, the familiar “stomach growling” referred to as borborygmi
-
Altered/Abnormal
- High-pitched tinkling
- Hyperactive
- Hypoactive
- Active/Normal
Bowel Sounds: High-pitched, tinkling bowel sounds
What are they an indication of?
Intestinal Obstruction (early): Normal flow of intestinal contents is interrupted. Intestinal fluid and air under tension in a dilated bowel. Multiple etiologies.
Bowel Sounds: Hyperactive bowel sounds
Cause?
- Diarrhea (gastroenteritis)
- Peritonitis (early)
Bowel Sounds: Hypoactive bowel sounds
How to assess?
Indication?
- Is it quiet, or is it silent?
- Listen for several minutes
- Ileus – little to no bowel activity (absent)
- Peritonitis – may be hyperactive initially, but eventually becomes hypoactive due to progressively severe inflammation, may progress to an ileus
Bruits
Where do you auscultate for bruits?
- Aorta
- Renal arteries
- Iliac arteries
- Femoral arteries
Percussion
Purpose?
Where do you percuss?
What is normal?
- Purpose: Assess distribution of tympany and dullness
- Done in a minimum of four quadrants
-
Normal: Tympany throughout with scattered areas of dullness representing fluid/feces, dullness of liver and spleen
- Tympany – predominates because of gas in GI tract
- Dullness – assess for organ enlargement (hepatomegaly, splenomegaly)
Abnormal Percussion
What sounds would you hear? Indication?
Distended abdomen
Protuberrant abdomen
- Distended abdomen that is tympanic throughout suggests intestinal obstruction or paralytic ileus
- Protuberant abdomen with bulging flanks and dullness should prompt evaluation for ascites (fluid in peritoneal cavity)
- Free fluid sinks to the dependent part of the abdominal cavity whereas gas-filled loops of bowel float to the top
Liver Size
How to measure?
Normal size?
-
Lower Liver Border
- Begin in an area of tympany and percuss upward toward the liver
- Note where dullness begins (represents lower liver border)
- Mark with pen
-
Upper Liver Border
- Begin in an area of lung resonance and percuss downward toward the liver
- Note where dullness begins (represents upper liver border)
- Mark with pen
- *Measure the vertical span of the liver in the midclavicular line (MCL), normal size is ~ 6-12 cm in MCL
Hepatomegaly
What is it?
Etiologies?
- Hepatomegaly – liver enlargement
- Etiologies:
- Cirrhosis
- Hepatitis
- Alcoholic liver disease
- Abscess
- Hepatic Tumor or Cysts
- Hereditary conditions
- Biliary/Cholestatic disease
- Heart failure
Spleen
When spleen enlarges, which direction(s) does it expand?
How to percuss? What are you percussing for?
- When spleen enlarges, it expands anteriorly, downward, and medially
- Percuss the left lower anterior chest wall from border of cardiac dullness, at the 6th rib, to the anterior axillary down to costal margin and note distribution of tympany to dullness
Bladder
Is the bladder palpable?
What are you percussing for?
Abnormalities: cause of tenderness or distention
- Usually non-palpable
- Percuss for tenderness and fullness in the suprapubic area
- Bladder volume must be > 400-600 mL before dullness appears
- Abnormalities
- Tenderness with cystitis
- Distention from urethral stricture, prostatic hyperplasia, neurogenic bladder, etc.
Palpation
Purpose
Technique
-
Purpose:
- Assess for areas of tenderness, muscular resistance, superficial masses and organs (liver, spleen, kidneys), size of aorta
-
Technique:
- Patient should have knees flexed and arms at sides
- Palpate lightly then deeply
- Minimum of four quadrants, epigastrium, periumbilicus, and suprapubic
Light vs. Deep Palpation
-
Light Palpation
- Elicits abdominal tenderness
- Assess for muscular resistance (guarding and rigidity)
- Identifies superficial masses and organs
-
Deep Palpation
- Delineates pain
- Identifies masses and organs
- Note their location, size, shape, consistency, tenderness, pulsations, mobility
- Palpate liver and spleen through respiratory cycle
- Inspiration moves liver and spleen inferiorly “take a deep breath”
- Expiration moves organs back into normal position
Muscular Resistance:
Guarding vs. Rigidity
-
Guarding (tensing)
-
Voluntary contraction of the abdominal wall muscles with palpation
- May diminish when patient is distracted
-
Voluntary contraction of the abdominal wall muscles with palpation
-
Rigidity (stiffness)
-
Involuntary reflex contraction of the abdominal wall muscles
- Persists over several examinations
-
Involuntary reflex contraction of the abdominal wall muscles
Deep Palpation: Abdominal masses
Examples of:
Physiologic
Inflammatory
Vascular
Neoplastic
Obstructive
- Physiologic (pregnant uterus)
- Inflammatory (Diverticulitis)
- Vascular (Abdominal Aortic Aneurysm)
- Neoplastic (Colon cancer)
- Obstructive (distended bladder or dilated loop of bowel)
Typical Sites Abdominal Pain
Origin of pain cuased in:
RUQ or epigastric pain
Suprapubic or sacral pain
Epigastric pain
Periumbilical pain
Hypogastric pain
RUQ or epigastric pain → from biliary tree and liver
Suprapubic or sacral pain → from the rectum
Epigastric pain → from the stomach, duodenum, pancreas
Periumbilical pain → from the small intestines, appendix, proximal colon
Hypogastric pain → from the bladder, colon, uterus
Referred Pain
Where does pain in the following areas originate from?
Acute Cholecystitis
What is it?
Location of pain? Radiates to…
Positive test?
- Inflammation of the gallbladder
- RUQ pain may radiate to right scapular area
- + Murphy sign (specialized exam)
Acute Pancreatitis
What is it?
Location of pain? Radiates to?
- Acute inflammation of the pancreas
- Epigastric pain may radiate to back
Acute Appendicitis
What is it?
Location of pain? Radiates to?
- Acute inflammation of the appendix
- Pain classically begins near the umbilicus then migrates to RLQ
- McBurney’s point
- + Psoas, Obturator, Rovsing Sign (specialized exams)
Acute Diverticulitis
What is it?
Location of pain?
- Acute inflammation of a colonic diverticulum (sac like mucosal outpouching)
- LLQ pain
Renal & Ureteral Pain:
- Acute Pyelonephritis
- What is it?
- Specialized exam?
- Nephrolithiasis
- What is it?
- Location of pain? Radiates to?
-
Acute Pyelonephritis
- Infectious inflammatory process involving the kidney
- + Costovertebral angle (CVA) tenderness (specialized exam)
-
Nephrolithiasis
- Stones that may lodge throughout the urinary tract
- Acute, severe, colicky flank pain that radiates down to the groin
Liver Palpation
Technique
What should a normal liver feel like?
Abnormal liver?
- Place your left hand behind the patient
- Place your right hand in RUQ (fingertips below the lower border of liver dullness and pointed toward costal margin)
- Have patient take a deep breath and feel for liver edge as it slides down to meet your fingertips
-
Normal liver edge:
- Soft, sharp, and regular with smooth surface
-
Abnormal liver:
- Firmness or hardness of liver, bluntness or rounding of its edge, and surface irregularity are suspicious for liver disease
Spleen Palpation
Technique
Etiology of splenomegaly
- Place your left hand behind the patient
- Place your right hand in LUQ, (fingertips below the left costal margin and pointed towards lateral chest)
- Have patient take a deep breath and feel for the tip or edge of the spleen as it slides down to meet your fingertips
- *Palpation must occur with deep inspiration
-
Splenomegaly Etiology
- Congestive diseases (cirrhosis with portal hypertension, heart failure, splenic vein thrombosis)
- Hematologic malignancies
- Viral (mononucleosis), bacterial, parasitic infections
Kidney Palpation
Technique
Etiologies of kidney enlargement
-
Left Kidney
- With your left hand, reach over and around the patient to lift up beneath the left kidney and with your right hand feel deep in the LUQ
- Attempt to capture the kidney
-
Right Kidney
- With your left hand, lift up from the back and with your right hand feel deep in the RUQ
- Attempt to capture the kidney
-
Kidney englargement: etiologies
- Hydronephrosis
- Cysts/Tumors
- Polycystic Kidney Disease
Aorta Palpation
What are you palpating for?
Technique?
Abdominal Aortic Aneurysm (AAA): define?
- Palpate for aortic size and pulsations
- Proximal to the umbilicus to the left of the midline, apply steady downward pressure with fingertips, one hand on either side of the aortic impulse
-
Abdominal Aortic Aneurysm:
- Focal dilation of abdominal aorta, diameter > 3 cm
Inguinal Exam
- Auscultate and palpate the inguinal region bilaterally for the following:
- Femoral bruits
- Femoral pulses
- Inguinal lymph nodes
- Inguinal hernias
- Ask patient to cough
- Inspect and palpate for bulge
Rebound Tenderness
Purpose
Technique
Positive test
Indication
- Purpose: Peritoneal irritation (peritoneal sign)
-
Technique:
- Press fingers slowly and gently into the abdomen and then quickly withdraw. Observe!
- Ask the patient “Which hurts more, when I press in or let go quickly?”
- Maneuver is positive
-
Positive test:
- If quick withdrawal of the fingers produces pain
-
Indication:
- In the RLQ, a positive sign may be suggestive of appendicitis
*If present, then classified as a peritoneal sign, which could be suggestive of intraperitoneal infection, ruptured viscus, etc.
Rovsing Sign
Purpose
Technique
Positive test
Variation of test
- Purpose: Peritoneal irritation (possible appendicitis)
-
Technique:
- Press gently and deeply in the LLQ
-
Positive test:
- Referred pain to the RLQ during left sided pressure
-
Variation: “Referred Rebound Tenderness”
- Press gently and deeply in the LLQ and quickly withdrawal your fingers
- Pain in the RLQ is a positive referred rebound tenderness
Psoas Sign
Purpose
Technique
Positive test
Rationale for test
- Peritoneal irritation (possible appendicitis)
-
Technique
- With patient supine: place your hand just above patient’s right knee and ask patient to raise thigh against hand (resisted straight leg raise)
- With patient lying on left side: extend patient’s right leg at the hip
-
Positive Sign
- Increased RLQ pain with either of these maneuvers
-
Rationale:
- Appendix lies closely to iliopsoas muscle. If the appendix is inflamed, any maneuver that contracts or stretches the iliopsoas muscle may cause increased pain in the RLQ
Obturator Sign
Purpose
Technique
Positive test
Rationale for test
- Peritoneal irritation (possible appendicitis)
-
Technique:
- With patient supine, flex patient’s right hip and knee and rotate leg internally at the hip
-
Positive Sign:
- Increased RLQ pain
- *May be positive with other etiologies. History is important.
-
Rationale:
- Internal obturator muscle lies closely to the appendix on the right. Stretching the internal obturator muscle in the setting of appendiceal inflammation may cause increased pain in the RLQ
“Shifting Dullness”
Purpose
Technique
Positive test
Indication
-
Testing for:
- Ascites
-
Technique:
- With patient supine, percuss the border of tympany & dullness
- Have patient roll onto his/her side, then percuss and mark the borders again
-
Positive Sign:
- An obvious shift in the location of the border
-
Indication:
- Suggests free intra- peritoneal fluid
“Fluid Wave”
Purpose
Technique
Positive test
-
Purpose:
- Ascites
-
Technique:
- Stabilize mid-abdomen with hand (patient or assistant applies pressure down the midline)
- Hold your hand against patient’s flank and tap the patient’s opposite flank with the fingertips of the other hand
-
Positive test:
- If free fluid exists, the examiner will feel a fluid wave strike his/her hand
Murphy Sign
Purpose
Technique
Positive test
Indication
- Purpose: Gallbladder/ hepatic inflammation
-
Technique:
- Position fingers of right hand under right costal margin, and apply pressure while having the patient take a deep breath
-
Positive test:
- A sharp halting in inspiratory effort due to pain from palpation of the gallbladder
-
Indication:
- Possibly suggestive of acute cholecystitis
CVA Tenderness
Purpose
Technique
Positive test
Indication
- Purpose: Kidney inflammation
-
Technique:
- Place the ball of one hand in the costovertebral angle and gently percuss it with the ulnar surface of your other fist
-
Positive test:
- Pain with first percussion
-
Indication:
- Potentially suggestive of kidney pathology (i.e., pyelonephritis) or a musculoskeletal cause
